Provider Demographics
NPI:1689014128
Name:CALLISON, KURT THOMAS (DO)
Entity Type:Individual
Prefix:DR
First Name:KURT
Middle Name:THOMAS
Last Name:CALLISON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:418 S HAMILTON ST
Practice Address - Street 2:SUITE 109
Practice Address - City:PAINTED POST
Practice Address - State:NY
Practice Address - Zip Code:14870-9705
Practice Address - Country:US
Practice Address - Phone:607-936-2089
Practice Address - Fax:607-936-8176
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY279917207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103055103Medicaid
NY04159835Medicaid
NYJ400228885Medicare PIN